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MENTAL HEALTH
CHALLENGES

continued from page 17
ASSESSMENT EVALUATION OF SUICIDAL IDEATION
DIAGNOSIS As it is so important to evaluate depressed patients for suicidal
There are nine different types of “depression” listed in the cur- risk, this concept will be discussed in detail. There is a myth that
rent diagnostic manual (DSM 5.) I will not attempt to elaborate asking about thoughts of death or suicide may “cause” someone to
upon the distinctions. With LLD, there are often numerous somatic consider suicide, and some providers will shy away from inquiry.
symptoms present. Their presence should not detract from focusing Experienced clinicians know that asking these questions is appreci-
on the same primary symptoms one uses in younger patients for a ated by the patients and show the clinician’s concern. These are im-
proper diagnosis. The major issue is that we do not diagnose de- portant symptoms to ascertain, as suicide may be a consequence of
pressive illness only because of “depression,” a mood change. In under or un-treated depression, and most patients who suicide have
fact, some individuals with a correct diagnosis of “depressive ill- recently seen a health care provider. Patients should never be told,
ness” actually deny a feeling of depression. There may be cultural “you can trust me…this is just between you and me,” as the physi-
factors which make it difficult or “wrong” to admit/discuss emo- cian may need to involve family, friends, or law enforcement if sui-
tional issues, and/or neurobiological reasons why some individuals cidal risk is high. Lack of documentation of this suicidal
may have numerous symptoms of depressive illness and yet deny ideation/plan/intent would not be seen favorably if litigation were
the mood of depression. However, it is mandatory to have either a to occur.
feeling of “depression” or anhedonia (inability or decreased ability
to experience pleasure,) for a two-week period for proper diagnosis. In addition to the risk factors for depression,
In addition, an accurate diagnosis would require four of the six fol- risk factors for suicide include:
lowing symptoms to be present during the same two-week period: * relationship dissolution
* death of spouse or partner
• decreased/low energy. The issue of decreased/low energy is
* illness, especially if associated with pain, disability, or loss of
quite subjective, and requires some time and skill to elicit prop-
independence
erly. Decreased/low energy means there has been a significant
* neurocognitive difficulty, (chronic/heavy alcohol abuse, TBI,
decrease in energy from that person’s normal functioning, taking
Parkinson’s disease, dementia)
into account their typical activities. For example, a person who
* financial/ housing /legal difficulty (loss of residence, pension
goes to the gym for 20 minutes twice a week may be having a
benefits, bankruptcy)
significant decrease in energy if last month they went for 45 min-
* new lack of compliance with medical treatment
utes four times per week, and now they are “too tired” to go
* increase of risky behaviors (fast driving, substance abuse)
more frequently. The key issue is whether or not their energy
* strange comments (“this is the last time you’ll see me” or
decrease prevents them from being involved in activities which
“I won’t be coming back.”)
they want to do.
* selling/giving away possessions
• psychomotor changes, observable slowed (or agitated) speech or * suddenly wanting to get affairs in order, writing a will.
behavior,
There is a continuum of questions one should ask elderly patients
• impairment in concentration (or indecisiveness) in areas of in-
regarding their attitude toward life, even if not depressed, as 15-
terest, and
50% of patients who successfully suicide do not have diagnosed
• changes in appetite is another important symptom to be consid- depressive illness. The questions start off very generally and become
ered for a diagnosis of depressive illness. Appetite changes usu- more and more specific if previous answers are concerning.
ally involve a decrease in appetite and weight loss, but it is * How are things going?
possible to have increased appetite as one becomes more de- * Do you enjoy life?
pressed. * Do you ever wish you were dead?
* Do you ever consider killing yourself?
• feeling worthless or guilty are common symptoms, and
* What are your thoughts about what happens to you after suicide?
• thoughts of death, suicide, or suicide attempts are important * What specific plans do you have for suicide?
symptoms whose presence or absence should be evaluated. * What steps have you taken to accomplish these plans? (purchased
a gun, bought a rope, read about suicide on the Internet.)

18 San Antonio Medicine • May 2019